24 year old male with vomiting, sob,and blood in urine

January 05, 2023

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.

Consent was given by patientand their attenders

A 24 year old male daily wage workers who usually does work at coal mostly came to opd with

Chief complaints:

decreased urine output , vomiting since 9 days .Difficulty in swallowing and oral ulcers and fever since 8 days

History of presenting illness:

Patient was apparently asymptomatic 9 days back then he developed severe vomitings due to an excessive binge drinking without any consumption of food. The vomitings were 4-5 episodes/day and were non bilious, non blood stained, non foul smelling, watery and occurred immediately after consumption of food or liquids. Also complaints of difficulty in swallowing since 8 days.

Patient developed oral ulcerations later that day. He was taken to a local hospital where medication (mouth wash and some gel for ulcers). was provided and did not get relief. 5 days ago he had complaints of shortness of breath and decreased urine output with blood in the urine.And went to a private hospital and endoscopy was advised and blood tests were done in which increased serum creatinine levels and bilirubin levels were detected and referred to our hospital and got admitted for dialysis. 4 days ago the patient was observed to develop a white coating in the mouth and over the tongue( dermatology opinion taken).

He has no H/o fever, loose stools, pedal oedema, pain abdomen, burning micturition, cold, cough .

Past history:

similar complaints in the past

No H/o HTN, diabetes, asthma, epilepsy and tuberculosis.

PERSONAL HISTORY:

Diet: mixed. Appetite: normal

Bowel and bladder: irregular.

Sleep: adequate.

Addictions : alcohol consumption since 4 yrs daily( around 180 ml) (binge drinking episode 2 days back before onset of present symptoms ) and paan occassionally.

Allergies: none.

Family history: not significant

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative moderately built and nourished